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Editorial
Aug 2012

Disparities in Health CareLack of Equity Arising From Overuse (and Vice Versa)

Author Affiliations

Author Affiliation: Division of Emergency and Urgent Care Services, Children's Mercy Hospital, Kansas City, Missouri.

Arch Pediatr Adolesc Med. 2012;166(8):770-772. doi:10.1001/archpediatrics.2012.1039

Equity, 1 of the 6 dimensions of health care quality identified by the Institute of Medicine, is defined as providing care that does not vary in quality because of personal characteristics such as sex, ethnicity, or socioeconomic status. Along with equity, the additional dimensions of safety, effectiveness, patient centeredness, efficiency, and timeliness constitute a set of aims for health care improvement set forth in the 2001 Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century.1

The topics of disparities in health care and equity are subjects of a separate Institute of Medicine report.2 This report describes the magnitude of the US health care disparity problem and presents a framework for understanding that includes examining possible causal factors at 3 general levels: that of the patient, that of the provider, and that of the system. An abundance of studies examining the relationship between race/ethnicity and both outcomes and health services use have found important disparities across the vast continuum of health and health care from prevention to chronic disease management. Within the pediatric medical literature, a fair amount of descriptive work has been done establishing child health and health care disparities that are extensive, pervasive, and persistent, touching nearly every venue of clinical and public health care.3

Equitable health care is the overarching topic in the study by Natale et al4 for the Pediatric Emergency Care Applied Research Network (PECARN) published in this issue of the Archives. The aim of the study was to measure the association of race/ethnicity with emergency department head CT use for children with minor yet nontrivial head injury. It was a secondary analysis of data collected for a primary study that created a set of prediction rules for clinically important traumatic brain injury. These rules constitute a tool to help clinicians decide when to obtain a head CT in children with minor head injury.5

Interestingly, Natale et al found that for children classified as high risk for clinically important traumatic brain injury, CT use did not differ among ethnic groups, but for those with moderate and low risk, it did, with the greatest disparity found in the lowest-risk group. In other words, white children appeared to get head CT scans more often than children of color when those CT scans probably were not clinically indicated. Whether race/ethnicity was a proxy for other factors (eg, socioeconomic status or insurance) was not addressed in the study, which Natale et al thoughtfully recognize.

In health care use disparity research, the question “Who is not getting what they should?” has been the traditional query. The converse is perhaps equally important. “Who is getting what they should not?” However, early discussions of health disparity tended to downplay overuse as the source of US health disparities.2

An understanding (and prevention) of health care disparities is incomplete without including work in both overuse and underuse of health care services. Equity only makes sense if it is applied to care that is safe and effective—and also efficient. The work by Natale et al and others points to a recognized and enormous American health care inefficiency problem, that of overuse. The study demonstrates that the waste in our health care system may result, in part, from the same factors or mechanisms that create inequities.

Overuse is a well-recognized but largely undealt with problem in US health care. It is perhaps nowhere more clearly demonstrated than in the use of diagnostic imaging studies. Overuse of CT scanning, in particular, has been well documented and the subject of efforts to curtail unnecessary use,6,7 especially because of a better understanding of the link between ionizing radiation and malignancies.8 Between 2000 and 2005, Medicare spending for diagnostic imaging increased from $6.6 billion to $13.7 billion, the majority of that growth accounted for by increased imaging with CT and magnetic resonance imaging.9 Despite the recognition of overuse, not much is known about the detailed pattern of those increases and causal factors. Financial motivation, which can exist in a fee-for-service model, does not account for the significant increases in imaging and cost per enrollee documented within large managed care organizations where financial incentives encouraging imaging generally do not exist.6 Besides diagnostic imaging, multiple other health care services have had similar significant increases. In the United States, the country with the highest proportion of the gross domestic product spent on health care, it has been estimated that perhaps 30% of medical care given is unnecessary.10

The Natale et al article is a wonderful hypothesis-generating piece of work in that it reveals some information about the patterns of overuse. Overuse of head CT for clinically insignificant injury differed by race in this study performed in large academic children's hospital emergency departments. The study also demonstrated a bigger influence of parental anxiety/request as a factor in ordering a head CT in white children compared with others. It is probable, in this setting, that there were not any significant financial incentives for ordering CT scans at the provider level and CT scans are relatively easy to obtain for all children presenting to these emergency departments. Thinking about these racial differences in the Institute of Medicine equity framework (patient, provider, system), we can ask a multitude of questions that deserve to be answered in pediatric clinical settings. Does expression of parental anxiety and worry differ based on race? Do providers perceive/interpret patient needs and anxiety differently based on race? Does communication differ based on racial concordance with the provider? What about anxiety/worry at the provider level? Do providers fear legal action or patient complaint based on race of their patients and is this what drives overuse? And importantly, is it really race driving these differentials or is race a proxy? What are the effects of educational level, social status, and income? A host of questions around interpersonal dynamics in the patient (parent)-provider interaction can and should be asked.

Additionally, how do system-level factors as they pertain to this study play into the creating of race/ethnicity differentials? Is the current trend in emphasis of consumer satisfaction driving any physician behavior in a differential way? Even in an environment (like the emergency department) where accessing payer status prior to providing treatment is not tolerated for a variety of ethical and regulatory reasons, is there unconscious biasing by race, perhaps perceived as a proxy for insurance status?

In addressing health care inequities, it is critical to first ask about the effectiveness and safety of the health care process or use measure in question. The true question should focus not on “too much” or “not enough” but “is appropriate care being equally provided?”

Efficiency, aka “reduction of waste,” is what Don Berwick has called the quality dimension of our time. Berwick has gone so far as to say that the credibility of the quality movement will rise or fall on success of reducing the cost of heath care. He points to several forms of waste that must be removed from the system to help both patients and sustain the system. The first among these is overtreatment, waste due to subjecting people to care that cannot possibly help them11 and, as this study suggests, may actually hurt them.

Natale et al and the PECARN group call for further studies to better understand how demographic factors like race/ethnicity play into medical decision making. Knowledge about the nuances of perception and communication and how the reciprocal nature of the provider-patient (parent) relationship influences health care use is meager, especially in pediatrics. Perhaps by bettering our understanding of behaviors resulting in inequities an important window into the root causes of health care waste will be opened. Efficiency is the least politically popular of all of the quality aims and adding an inequity dimension to it makes it all the more thorny. But in a system of finite resources, one would argue that measures toward efficiency will help move us toward equity at least from a systems point of view. Overconsumption of health care for subsets of a population drives up the cost for all, ultimately putting those who are uninsured at greater risk. Economists might argue otherwise, viewing efficiency and equity as mutual trade-offs.

Discerning and managing the often delicate balance between efficiency, safety, timeliness, equity, and patient centeredness is difficult and will never be handled well by a practice guideline or set of rules, including laws. Reducing waste and minimizing harm while being patient centered and equitable in our care calls on the best of our science and as well the best of the art of medicine. For that to happen, we will need to develop better insight into why we do what we do at the bedside.

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Article Information

Correspondence: Dr Dowd, Division of Emergency and Urgent Care Services, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108 (ddowd@cmh.edu).

Financial Disclosure: None reported.

This article was corrected for errors on September 7, 2012.

REFERENCES
1.
Institute of Medicine.  Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001
2.
Institute of Medicine.  Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: The National Academies Press; 2003
3.
Flores G.Committee On Pediatric Research.  Technical report: racial and ethnic disparities in the health and health care of children.  Pediatrics. 2010;125(4):e979-e1020PubMedArticle
4.
Natale JE, Joseph JG, Rogers AJ,  et al; Pediatric Emergency Care Applied Research Network.  Cranial computed tomography use among children with minor blunt head trauma: association with race/ethnicity.  Arch Pediatr Adolesc Med. 2012;166(8):732-737
5.
Kuppermann N, Holmes JF, Dayan PS,  et al; Pediatric Emergency Care Applied Research Network (PECARN).  Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.  Lancet. 2009;374(9696):1160-1170PubMed
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Brenner DJ, Hall EJ. Computed tomography: an increasing source of radiation exposure.  N Engl J Med. 2007;357(22):2277-2284PubMed
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MedPAC.  Data Book. www.medpac.gov/. Accessed April 18, 2012
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Reilly BM, Evans AT. Much ado about (doing) nothing.  Ann Intern Med. 2009;150(4):270-271PubMed
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Berwick D. The Moral Test. Presented at: Institute for Healthcare Improvement National Forum; December 7, 2011; Orlando, FL
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